NCP kidney disease – the reality

August 27, 2012, 10:15 pm

By Dr.C.Weeraratna (csweera@sltnet.lk)

Former Professor of Soils and Water Resources, Rajarata University

Since the year 2000, Chronic Kidney Disease of unknown etiology (CKDU) also called Chronic Renal Failure (CRF) has been reported to occur in several areas of Sri Lanka, mostly in the North Central Province (NCP), The total number of affected individuals is unknown, but it is around 10,000, most of them in NCP. A large number from Badulla and Kurunegala districts are also affected by CKDU. In 2005, Anuradhapura Teaching Hospital alone recorded 140 deaths due to CKDU. Although renal diseases were found in other parts of the country it was not the CKDU

Meetings on CKDu

A number of meetings/discussions on CKDU have been held during the last few years.

A seminar on CKDU, organized by the Faculty of Graduate Studies of the University of Sri Jayewardena pura, was held on 12 Dec. 2011. According to the deliberations at this seminar, CKDU is more prevalent among men , typically around the age of 40-60 years, engaged in agriculture. The patients affected by CKDU are mostly in NCP in addition to some parts of North Western and Uva provinces. It is a major health and socio-economic problem in a number of DS Divisions such as Medawachchiya, Kahatagasdigiliya in North Central Province. Around 1500 people in NCP have reached the end stage of CKDU. The only treatment for them is dialysis which has to be carried out atleast once a week and there are not enough dialysis machines in the hospitals in the affected districts. It costs around Rs.6,000-10,000 for a dialysis, and most of the affected people cannot afford this. As a result , a large number of CKDU patients and their families are in a desperate situation. It was revealed at this seminar that people provided with water from Thuruwila water project of the Water Supply and Drainage Board are not affected by CRF.

To discuss the ‘Current aspects of CKDU in Sri Lanka’, a seminar for media personnel was held on March 10, 2012, It was pointed out at this seminar that the geo environmental and socio economic characteristics of the region were unique in many aspects, adding that the presence of high levels of fluoride, pesticide, arsenic and heavy metals in soils, and water sources could be a contributory factors to the high presence of CDKU in the NCP.

Ministry of Health (MOH) initiated a research study in Oct. 2008 on CKDU. to be carried out in collaboration with WHO- Colombo. The study was conducted by the National Research Programme for CKDU, to find the causal factor of CKDU and other related issues. According to this study "Hard water -cause of kidney problems in NCP. In The Nation 19 August 2012, World Health Organization (WHO) expert Dr Shanthi Mendis who spearheaded the WHO funded National Research Program has described CKDU as "A combination of risk factors toxic to the kidney, which included nephrotoxic agrochemicals, Arsenic and Cadmium, as well as genetic factors. She has said that drinking water was unlikely to be the source of the arsenic and cadmium exposure causing CKDu and cited fertilizer and agrochemicals as actual reasons and called for stringent measures to reduce harmful health effects.."

The latest seminar on CKDU, organized by the Ministry of Water Supply and Drainage was held in Anuradhapura on the 16th August 2012. At this seminar, a report of the study on CKDU, conducted by Center for Science and Environment (CSE) in India and Center for Environmental Justice, Sri Lanka (CEJ) was presented by Mr. Chandra Bhushan of CSE and Mr. Hemantha Withanage of CEJ.

The results of this study indicate that water samples collected from North Central Region are not contaminated with heavy metals. Arsenic or other heavy metals could not be clearly and directly related to the etiology of CKDU. Only fluoride levels detected in the water samples were between 0.5 and 1.7 mg/l, a little above twice the desirable levels set by Sri Lanka standards. As the desirable limit for fluoride is 0.6 mg/L in Sri Lanka and levels detected in the present study are higher, fluoride at these levels over a long period of time is a possible risk factor responsible for kidney diseases. The cadmium, arsenic, chromium and lead contents in drinking water, rice from affected regions and soil from affected areas were not detectable in the study indicating that heavy metals are not a contributing factor for CKDU in Sri Lanka.

According to separate studies carried out by a number of Sri Lankan scientists, CKDU is attributed to a toxic element/s or compound/s in drinking water. Among these constituents are cadmium, fluoride, aluminum, toxins released by Blue Green Algae, pesticides etc.

Aresnic- a causal factor?

According to a news paper item titled " Arsenic cause of NCP kidney disease which appeared in the Island of 18th August 2012, a research team, at Kelaniya University conducting studies on CKDU had found traces of arsenic (As) in tissues of hair, and nail. Autopsies that had been performed, on patients who died of CKDU, had also revealed traces of arsenic in hair and nails. According to the above article in the Island, the research team at Kelaniya University identified arsenic, a deadly carcinogen, as one of the key causes of CKDU. It is not clear how they arrived at this conclusion.

If fertilizers and pesticides are the sources of As, importation and use of such should be banned. But before that it is important that the fertilizers and pesticides which contain As are identified by appropriate tests. It is important to point out that if the source of Arsenic is fertilizers and/ or pesticides, then water in other districts such as Kandy, Nuwara Eliya , Hambanthota etc. where large amounts of fertilizers and pesticides are used should also have high contents of these heavy metal, and the people in those areas should also be affected by CRF.

It is relevant to point out that Fertilizers and Pesticides are not the only sources of Arsenic and other heavy metals Rocks in some areas and therefore the soils derived from such rocks may also contain As and other heavy metals. Some organic fertilizers such as compost may also contain these heavy metals if solid wastes have been used in the manufacture of organic fertilizers.

Dr Guha Mazumder, Director DNGM Research Foundation (Web Site : www.dngmresfoundation.org) and Member of the Task Force on Arsenic in West Bengal had been working on chronic As toxicity in West Bengal for about 28 years. He has not come across any case of chronic renal failure associated with chronic As exposure.

Widespread arsenic contamination of groundwater has led to a massive epidemic of arsenic poisoning in Bangladesh and neighboring countries. It is estimated that approximately 57 million people in the Bengal basin are drinking groundwater with arsenic concentrations elevated above the World Health Organization’s standard of 10 parts per billion (ppb). The arsenic in the groundwater is of natural origin, and is released from the sediment into the groundwater, owing to the anoxic conditions of the subsurface.. Many other countries and districts in Southeast Asia, such as Cambodia have geological environments conducive to generation of high-arsenic levels in groundwater.

Fertilizers and Pesticides

Authors of some articles in the electronic and print media, appear to be of the opinion that we need not use chemical fertilizers (Fs) and pesticides (Ps), because in the past these were not used in crop production. Of course it is best if we can produce crops without using Fs and Ps. Use of these Fs and Ps cause environmental pollution and tend to increase Cost of Production. All Pesticides are toxic compounds. Toxicity is indicated by what is called LD 50 values. Those of low LD 50 values are more toxic than others. Although Fs and Ps were not used a few decades ago, the biotic environment including the level of the fertility of soils is not the same as was in the past, resulting in the need to use these Fs and Ps. New pests (insects, fungi, bacteria etc.) keep on developing and unless these are effectively controlled, there could be food shortages. There may be a few plots cultivated without Fs and Ps using modified/different agronomic/spiritual methods. It is necessary to find out how effective these methods are. If they are effective, the researchers of the Dep. of Agriculture need to make recommendations based on their findings. It is also necessary that Integrated Pest Management (IPM) methods are developed and applied so that we could give up the use of synthetic toxic chemicals to control pests. In countries such as India, pests are controlled mostly using IPM

What Needs to be done:

According to the article indicated above, the researchers investigating CKDu at Kelaniya University are trying to find an alternative treatment for this disease, as the only available western medicine currently available is inadequate. According to Head of the Chemistry Department of the Kelaniya University, researchers are testing an indigenous medical preparation using herbs and vegetables. They are simultaneously looking into the possibilities of clearing the soil of arsenic by trying to promote the growth of trees and plants which can control arsenic and other poisonous substances while softening the quality of water. Scientists in other organizations are also conducting studies on different aspects of CKDU.

It will take a few years before the results of all these studies are available. While the scientists are carrying out their "studies" on CKDU it is extremely important that action is taken to reduce the occurrence of this lethal renal disease which is causing untold hardships to the thousands of poor people in three provinces of the country.

There is a need for a comprehensive public health effort to effectively address the problem of CKDU. This should be taken as a National Priority with the main responsibility resting on the Ministry of Health. This ministry and their counterparts in the affected provinces with the relevant officers need to take more effective actions to implement an integrated programme in association with other responsible authorities, to prevent/control the occurrence of CKDU. The Minister of Water Supply and Drainage with his officers have contributed much in this regard which should be highly appreciated.

From the observations and results of various studies carried out so far it could be assumed that CRF is caused by a toxic elements/s or compounds in water. Hence, methods of detoxifying water needs to be developed. Dr. U. Pethiyagoda, ( Ref. The Island 6th January 2011) has suggested the use of powdered dried seeds of murunga (Moringa oleifera) to purify water. A filter has been developed by the Water Supply and Drainage Board to remove fluoride from water. Institute of Fundamental studies has developed an electro-chemical method of removing fluoride from water. The suitability of these method needs to be tested by an appropriate authority.

One way of reducing the incidences of CKDU is implementing a programme to supply good quality water to those in the affected areas. People in the city of Anuradhapura who are supplied with water from Thuruwila by the National Water Supply & Drainage Board are not affected by CKDU.

If CKDU is proved to be caused by As and / or other heavy metal it is also important that importation and use of fertilizers and pesticides containing these toxic elements/compounds is banned.

Rainwater:

Rainwater is the most pure form of water. It is almost free of toxic elements/compounds. A considerable portion of the rainwater that falls on the roofs of buildings can be collected in tanks in the premises itself. Water that falls on a roof of 1,000 sq m in an area where the average annual rainfall is 2,000 mm, would be around 2,000 cubic meters (i.e 2 million liters or app. 400,000 gallons). Water thus collected would be free of toxic substances and could be used for numerous domestic purposes including drinking.